Racism, classism, and who we take into medical school: Who will care for the people?

I work in a medical school. I see and teach medical students. They are a smart group. When measured by grades and scores on standardized exams, they are even smarter. Some of them – but not nearly enough – are members of socioeconomic and ethnic groups or geographic areas under-represented in medicine. Sometimes, these students struggle with grades in medical school. Occasionally, this elicits comments, sometimes smug, sometimes rueful, that this is the result of affirmative action, as if this were a negative thing. Given the alternative, the default of taking all people who look alike, who come from the same background, who want to do the same things – in brief, to stereotype, white 22 year old men who come from economically privileged and professional families (many of them medical) who want to be subspecialists in the suburbs – this is pretty scary.

It is affectively, intellectually, and morally scary, yes, to think that we could accept this kind of regression to an archaic, not to say racist and classist past where becoming a doctor was a privilege limited to only a few. It is also scary in very practical terms, because the people who need health care the most are those least likely to be served by the “default” group. Indeed, in fulfilling their personal goals, the result will be to “serve” already overserved communities, largely in specialties in oversupply. There is good data that shows that students from rural areas are more likely to serve rural communities, that students from underrepresented minority groups are more likely to serve members of those groups, that students from less-privileged backgrounds are more likely to serve needier communities. And that all these groups are more likely to enter primary care specialties, those in most short supply. This is what we want. But they represent a small percentage of our medical students. Why? Because we still, despite all the data showing what predicts service to people most in need, stay wedded to incorrect and outdated ideas of “qualified” for medical school that overwhelmingly bring us the same old same old.

Many (although clearly, given the above, not most) of medical students, from all backgrounds, have some difficulty with the first two years of medical school despite being not only smart but are well-educated from top small liberal arts colleges. There is a relationship here; these colleges emphasize thinking and creativity and problem solving, exactly the skills needed to be an effective physician. They teach largely in small and interactive classes, fostering self-confidence and independence and thoughtfulness and sometimes non-conformity, exactly the temperament needed for an effective physician. They grade largely on the basis of essay tests, requiring integration of information, literacy, and demonstrating an ability to think, not on multiple-choice tests, just what we want from physicians. Unfortunately, this is not the best preparation for the first two years of medical school, overwhelmingly consisting of large lectures characterized by a presentation of a huge number of facts, and designed to reward memorization of those facts using massive multiple-choice tests. Good preparation for this: being a science major at a large university whose courses overwhelmingly consisted of large lectures characterized by a litany of factoids and rewarding successful regurgitation of those factoids on massive multiple choice tests. QED.

Not, of course, the best preparation for being a curious, open-minded, thinking, problem-solving doctor. But this is what we get. Yes, it is certainly true that some of our students from large universities, or from professional or high socioeconomic status, or majority ethnic groups, or suburbs, or all, are incredibly committed to making a difference. Many want to enter primary care, many more want to serve humanity’s neediest, in our country and abroad. They are humble, and caring, and smart. We are lucky to have them in our schools and entering medicine. But they, along with those who are from less-well-off families, and ethnic minority groups, and rural communities, remain a minority among all the sameness. And remain more or less in the same proportions over time. We continue to do the same thing, and have the audacity to wonder why we do not get different results. This is Einstein’s definition of insanity.

On November 16, 2014, Nicholas Kristof published his column “When Whites Just Don’t Get It, Part IV” in the New York Times. He discusses the continuing racism in this country, the legacy of slavery, the fact that “For example, counties in America that had a higher proportion of slaves in 1860 are still more unequal today, according to a scholarly paper published in 2010.” And, of course, he discusses the responses he received (from white people) to Parts I-III, saying it is all in the past, stop beating that drum, it is not my fault, I work hard and don’t get the special privileges that “they” do, and why don’t they take personal responsibility, and our President is Black, isn’t that proof that the problem is gone? I won’t begin to get into the question of how much of the vicious attacks on our President are in fact the result of the fact that he is Black; rather while I observe that the fact that he was elected says “Yes, we have made incredible progress,” I note that this does not eliminate “Yes, we still have lots of racism and it has major negative effects on people as individuals and society as a whole.”

Kristof talks about the fact that he and his Times colleague, Charles Blow, are both promoting books. He notes that while he (Kristof) is white and from a middle-class background, Blow is black and was raised largely in poverty by a single mother. But he also makes clear that this doesn’t prove that the playing field is even, but rather that Blow was very talented, very hard working, and also lucky. That some members of minority groups, or people with very disadvantaged backgrounds (or both) succeed is a testimony to them, to their drive and intelligence and talent and luck, and the support that they have had from others such as family or friends which, while obviously not financial, was significant. It absolutely doesn’t prove that those who are from such backgrounds who have not succeeded are at fault. Indeed, the converse is true; how many of those who are from well-to-do, educated, privileged and white backgrounds, who have had all the financial and educational supports all their lives, who are now in medical school or doctors or professors or leaders of industry would have gotten there if they had started as far down the ladder as, say, Charles Blow, or some of our medical students? Some, for sure, but not most. They are folks born on second, or even third, base, who make it home and look at those who started from home and made it around all four bases, and say “why can’t they all do that”? Most of you, starting in the same place, would, like those who actually did start there, never have had a prayer.

It is common for classes of medical students to develop a “personality”, more self-centered or more volunteering, more intellectually curious or more grinding, more open or more closed. I suspect that this probably has to do with a few highly visible people, because most of the students don’t vary that much. I have heard faculty complain about the inappropriate behavior, the lack of professionalism (especially when they get to the parts of school that involve caring for patients), the sense of “entitlement” that many students have. But this is not true (overwhelmingly) of those who are the first in their families to go to college, who are grateful for the opportunity and hard-working, and committed to making a difference in the world. If we think that entitled, unprofessional students are not desirable, why are we accepting those who fit that mold?

We can do better. We can scale up programs to accept caring, humble, committed, smart people instead of self-centered, arrogant, and entitled ones. Indeed, if we hope to improve the health of our people, we must.